Monday, March 31, 2014

In a post yesterday, I suggested that someone “could take statements from the strongest critics of biopsychiatry, mix them with those of leading psychiatric representatives, and people would be at a loss to identify which group the source came from.” I’d like to test that out. Can you guess, for each of the following statements related to the scientific validity of psychiatric diagnoses, whether it came from a critic or an advocate?

1. “No biological markers [for any mental disorders in the DSM (other than the organic disorders epilepsy, Alzheimer’s, and Huntington’s)] have been identified.”

7. “Chemical imbalance rhetoric always seems to ignore one huge fact and that is Eric Kandel's classic article on plasticity in 1979 in the New England Journal of Medicine. Certainly any psychiatrist who saw that article has never bought into a ‘chemical imbalance’ idea…”

9. “[T]he field has…failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacological treatment.”

10. “[N]ot even one biological test is ready for inclusion in the criteria sets for DSM‐V.”

11. “[S]cientists [and] clinicians [cannot] point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group.”

12. “[T]he disorders [in the DSM] are not generally treated as heuristic, but to a great degree have become reified. Disorders within the DSM-IV or ICD-10 are often treated as if they were natural kinds, real entities that exist independently of any particular rater.”

13. “The molecular and cellular underpinnings of psychiatric disorders [are] unknown;…psychiatric diagnoses seem arbitrary and lack objective tests; and there are no validated biomarkers with which to judge the success of clinical trials.”

14. Psychiatry has been waiting for biomarkers for several decades; they’re “still waiting.”

15. “The weakness [of the DSM] is its lack of validity. Unlike…definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”

16. “Every marketer’s dream is to find an unidentified or unknown market and develop it. That’s what [Paxil marketers] were able to do with social anxiety disorder.”

17. “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.”

*

*

*

*

*

*

*

*

*

*

*

None of these is from a critic - they’re all from proponents of biopsychiatry, many from its highest ranks. Here are the sources:

1. Robert Spitzer, Chair of DSM-III Task Force, interviewed by James Davies for Cracked

Sunday, March 30, 2014

War is no longer declared,
only continued. The monstrous
has become everyday. The hero
stays away from battle. The weak
have gone to the front.
The uniform of the day is patience,
its medal the pitiful star of hope above the heart.

The medal is awarded
when nothing more happens,
when the artillery falls silent,
when the enemy has grown invisible
and the shadow of eternal armament
covers the sky.

It is awarded
for desertion of the flag,
for bravery in the face of friends,
for the betrayal of unworthy secrets
and the disregard
of every command.

I don’t really need to respond to each of these in detail, though. Everyone in the atheist-skeptic community should know what the responses are, because these are the same sorts of defenses and attacks we deal with from the promoters of religion and all manner of pseudoscience and quackery. The atheist and skeptical community has never extended the sort of solicitude being demanded of me to those making false religious or other quack claims. We regularly contest the false claims made by people like Mayim Bialik, Suzanne Somers, or Jenny McCarthy, even though they’re blended with personal narratives, because we don’t want to see people make choices about their own or their children’s health, or influence others to do so, based on dangerous pseudoscience. We’ve often pointed out that, while it’s unreasonable and unfair to suggest that someone who’s dedicated time and energy to investigating the evidence and writing about pseudoscience doesn’t care about the people affected by it, even if this were true it’s irrelevant to the reality. And so on.

What I suppose has been most surprising to me in these interactions is realizing just how firmly entrenched biopsychiatry is in our culture. It’s become so hegemonic that its leading promoters don’t have to do much of the work anymore. In fact, they can openly admit, in interviews and public statements, that it’s scientifically invalid to the core, and everything will continue as usual! Imagine if the people at the highest levels of research and clinical practice in another medical specialty produced several statements announcing that the diseases their field has for decades claimed to research and treat don’t exist, and that they’ve actually known this for decades. Now imagine that nothing really changes as a result. Some major news outlets report the field-shattering revelations…and then advise people to keep basing their medical decisions (and their very identity) on these empty, invalid notions. The news is generally ignored in the field and outside it, and the harms of basing medicine on this pseudoscience – though well known – receive no attention. The specialty’s critics, who are saying the very same things as its leading lights, continue to be dismissed and attacked. People continue to be forced by the government to accept the specialty’s pseudoscientific labels and “treatments,” and these are also applied to millions of children. And the model, acknowledged pseudoscience, continues to be exported to other countries with the false imprimatur of science.

It’s all enough to produce a weariness, a sense of futility. That weariness isn’t permanent, but it does add a cynical cast to your reaction even to positive developments. So it’s in that spirit that I’ll share some recent developments, particularly related to the lack of validity of the DSM diagnoses and the model as a whole.

Earlier this month, Richard Shulman managed to publish an op-ed critical of psychiatry in a small mainstream newspaper, which is something in and of itself. I enjoyed it for its plain-talking New England style, which contrasts so nicely with psychiatry’s spin:

The Connecticut Forum will soon host a panel of celebrities and professionals to take “An Honest Look at Mental Illness.” The selected panelists’ consensus is that science has demonstrated that ‘mental illnesses’ are illnesses – biological diseases of bodily tissue… (and that pharmaceuticals are indispensable).

The problem: Prominent psychiatrists – the same people who promulgated this view – now admit that this isn’t demonstrated fact. Never has been.

Shulman had already discovered this in the course of his professional work:

For 20 years I served on the Institutional Review Board (IRB) of Hartford Hospital–Institute of Living, an ethics-in-research committee. IRBs ensure that potential research participants are told the truth about their medical or psychiatric conditions. “Informed Consent” is the medical ethics doctrine requiring that people be given accurate, understandable information; to make their own decisions based on honest assessments of their conditions, and the known risks/benefits of their options.

Researchers (whether funded by drug companies, government or others) are required to submit to IRBs their research designs, including comprehensive summaries of previous research. Buried in pages of background, these scientists repeatedly admit that the conditions we mislabel “psychiatric illnesses” are simply not documented to be diseases of the body – despite decades of attempts to verify biomarkers, specific lesions or physical/chemical malfunctions that might cause these “conditions.”

No reliable, reproducible research has ever demonstrated people’s sadness (“depression”) or a child’s rambunctiousness (“ADHD”) to be physically rooted in tissue abnormality; nor is there an identifiable brain disease called “schizophrenia.” Physical confirmation of “mental illness” is unavailable in research, hence absent in clinical practice.

My favorite line from the piece: “Markedly different rules of science, logic and culture apply in psychiatry compared to medical science.” This couldn’t be truer. That’s what makes it all the more astonishing that so many doctors and researchers in scientifically valid specialties have taken it upon themselves to defend biopsychiatry as scientific medicine; these defenses comes at the cost of the loss of credibility of both medicine and science.

Bruce Levine: …[R]ecently, establishment psychiatrists have even been challenging the validity of psychiatry’s diagnostic bible, the DSM. Last year, NIMH director Insel, citing the DSM’s lack of scientific validity, stated that the “NIMH will be re-orienting its research away from DSM categories.” And psychiatrist Allen Frances, the former chair of the DSM-4 task force, has been talking about how the DSM is a money machine for drug companies (“Last Plea To DSM-5: Save Grief From the Drug Companies”), and Frances thoroughly trashed the DSM-5 in his 2013 book Saving Normal.

Robert Whitaker: I think this challenging of the validity of DSM is, in many ways, potentially much more of a paradigm-changer than are the scientific reports that detail how the medications may be causing long-term harm. Our current drug-based paradigm of care, which presents drugs as treatments for the symptoms of a “disease,” stems from DSM III. The APA [American Psychiatric Association] and its leaders boasted that when DSM III was published in 1980, that the field had now adopted a “medical model,” and thus its manual was now “scientific” in kind.

In fact, the APA had adopted a “disease model,” and if you carefully read the DSM III manual, you saw that the authors acknowledged that very few of the diagnoses had been “validated.” The APA’s hope and expectation was that future research would validate the disorders, but that hasn’t happened. Researchers haven’t identified a characteristic pathology for the major mental disorders; no specific genes for the disorders have been found; and there isn’t evidence that neatly separates one disorder from the next. The “disease model,” as a basis for making psychiatric diagnoses, has failed.

We are now witnessing, in Insel’s statements and those by Allen Frances, an acknowledgment of this failure. And here is why this is potentially such a paradigm-changer: The foundation of any medical specialty begins with its diagnostic manual, which should be both reliable and valid. If the disorders listed in a manual haven’t been validated, then you can’t conclude they are “real,” in the sense of the disorders being unique illnesses, and the diagnoses being useful for prescribing an appropriate treatment.

Thus, when Insel states that the disorders haven’t been validated, he is stating that the entire edifice that modern psychiatry is built upon is flawed, and unsupported by science. This is like the King of Psychiatry saying that the discipline has no clothes. If the public loses faith in the DSM, and comes to see it as unscientific, then psychiatry has a real credibility problem on its hands, and that could prove to be fertile ground for real change. [my emphasis]

What have been fascinating – and horrifying – to witness are the ways these admissions are being handled by the representatives of the profession. In the responses to the public acknowledgment that psychiatric illnesses and disorders don’t exist in the way the public has been led for decades to believe, some have argued that, well, we’ve all misunderstood what they mean by illness. Philip Hickey is one of the people who’s been pressing the validity issue, and provides a useful analysis** of an article by Awais Aftab in Psychiatric Times. Aftab’s piece is an attempt to defend the application of psychiatric diagnoses despite the complete lack of any medical-scientific justification (framed, for some reason I can’t quite figure, as a refutation of Thomas Szasz specifically). Hickey presents Aftab’s argument and explains the double game the psychiatric profession has been playing with terms like “illness” and “disease.” “For the most part,” Aftab claims, “disease is understood largely in terms of suffering and functional impairment, which may or may not be associated with a structure lesion.” Hickey replies:

The first question that arises is: “understood” by whom? I suggest that for most people, including physicians, the presence of an underlying causative pathology is an essential component of disease. When physicians, other than psychiatrists, talk about disease, they are talking about underlying causative pathology.

In contrast, in psychiatry, illnesses are what’s declared to be so:

[T]hat’s all there is to it. All significant problems of thinking, feeling, and/or behaving are illnesses, because we say so. Ultimately it always comes down to this. Psychiatrists routinely dress this kind of spurious nonsense in confusing verbiage, but if you cut away the chaff, the kernel is always the same.

Dr. Aftab seems to be under the impression that calling problems of thinking, feeling, and/or behaving illnesses has some explanatory value. The “logic” presumably goes like this: any kind of suffering and functional impairment, even in the absence of organic pathology, is an illness. So if a person so afflicted asks why he is suffering and functionally impaired, the correct answer (i.e. the explanation) is: because you have an illness. But the only justification for conceptualizing the suffering as an illness is because psychiatrists, including Dr. Aftab, have arbitrarily and, I suggest, misleadingly chosen to call these problems illnesses. The notion that one can explain human emotions and actions by assigning labels makes a mockery of genuine scientific enquiry.

… Psychiatry’s decision to call all significant problems of thinking, feeling, and/or behaving illnesses is arbitrary. It is a labeling process with no ontological underpinning and no explanatory value. It is also misleading, because the term “illness” already had a perfectly clear meaning before psychiatry commandeered it for its own purpose. [my emphasis]

Aftab also resorts to the argument (related to the claim that everyone understands that these diagnoses are merely “useful” and “convenient” “heuristics”), that “‘Mental disorder’ continues to be used because there is no appropriate substitute for it.” Hickey responds:

This is almost a straight quote from DSM-IV, p xxi:

“…the term [mental disorder] persists in the title of DSM-IV because we have not found an appropriate substitute.”

And this is the great psychiatric falsehood. There is a perfectly acceptable substitute. Significant problems of thinking, feeling, and/or behaving could be called: significant problems of thinking, feeling, and/or behaving. If the APA, or Dr. Aftab, were sincerely looking for a label that accurately reflected the subject matter, that, or something similar, would work perfectly well.

The reason they don’t do that, however, is because they cling – like drowning men to life rings – to the spurious notion that these problems are illnesses – medical entities –because it is only through that absurdly transparent ruse that they can continue to claim competence in the field and go on justifying the destructive and ineffective treatments that they inflict on the people who come to them for help.

A comment from Ronald Pies (whose argument Hickey addressed in the past) on the Psychiatric Times article caught my eye, because I’m accustomed to seeing this sort of language play not from doctors but from woo peddlers:

We do not require a “biological explanation” of the brain processes that may fuel such “mental” dysfunction, in order to characterize the person as having “disease” (a term derived from the prefix, “dis-” and the suffix, “-ease”). Of course, many of the major psychiatric disease states, such as schizophrenia, have clearly demonstrable biological correlates, if not proximate causes [this is false - SC]--but knowledge of these biological underpinnings is not necessary for the attribution of the term “mental illness” or “psychiatric disease”.

Ah, the old “dis-ease.” The problem is the fundamental dishonesty of these arguments – the way the general understanding of “illness” and “disease” is being played on. A “patient” seeking help from a psychiatrist, doctor, or therapist, receiving a “diagnosis” of a “mental illness,” and being given a prescription for a “medication” is obviously not being informed that these terms are not being used in their ordinary medical sense. And the public is obviously led to believe that psychiatry has actually identified real medical illnesses and not simply declared them to exist based on a vote or consensus.

Obviously I can’t dictate to psychiatrists how they should and should not use words. If they choose to call problems of this sort illnesses, then that’s their business. But they should also acknowledge that they are using the word illness in a distorted and misleading sense of the term.

They are also deviating from the ordinary standards and procedures of medical science.

… They cling to the unacknowledged extended use of the term illness in these kinds of deliberations and decisions, whilst maintaining the pretense in their practices and promotional literature that the word is being used in its classical sense of organic pathology.

Misleading people to believe that they’ve identified organic pathologies has of course taken the specific form of the longstanding chemical imbalance claim. Their responses to the ongoing efforts to debunk this myth have been obscenely disingenuous. David Healy’s blog recently featured a piece by Peter Gøtzsche, “Psychiatry Gone Astray.” It consisted of a series of refutations of common psychiatric myths, and elicited criticism from George Dawson at Real Psychiatry. Gøtzsche’s first myth is the chemical imbalance idea, and here’s his response to Dawson’s criticism:

Myth 1: Your disease is caused by a chemical imbalance in the brain

Dawson:“This is a red herring that is frequently marched out in the media and often connected with a conspiracy theory that psychiatrists are tools of pharmaceutical companies who probably originated this idea. What are the facts?” [Dawson adds later: “…Chemical imbalance rhetoric always seems to ignore one huge fact and that is Eric Kandel's classic article on plasticity in 1979 in the New England Journal of Medicine. Certainly any psychiatrist who saw that article has never bought into a “chemical imbalance” idea and I can recall mocking the idea when pharmaceutical companies presented it to my colleagues and I [sic] in medical school.” - SC]

The facts are abundant. Many papers written by psychiatrists have stated this, and it is also what most patients say that their psychiatrists tell them. I have lectured for patients and asked them, and every time most patients say they have been told exactly this hoax about a chemical imbalance. The drugs don’t cure a chemical imbalance; they create one, which is why it is difficult to get off them again.

Surprised to see the chemical imbalance idea referred to as a “red herring”? You’re surely not alone. The retreat from this claim is also noted in the Levine/Whitaker interview:

Bruce Levine: In Anatomy of an Epidemic, you also discussed the pseudoscience behind the “chemical imbalance” theories of mental illness—theories that made it easy to sell psychiatric drugs. In the last few years, I’ve noticed establishment psychiatry figures doing some major backpedaling on these chemical imbalance theories. For example, Ronald Pies, editor-in-chief emeritus of the Psychiatric Times stated in 2011, “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” What’s your take on this?

Robert Whitaker: This is quite interesting, and revealing I would say. In a sense, Ronald Pies is right. Those psychiatrists who were “well informed” about investigations into the chemical imbalance theory of mental disorders knew it hadn’t really panned out, with such findings dating back to the late 1970s and early 1980s. But why then did we as a society come to believe that mental disorders were due to chemical imbalances, which were then fixed by the drugs?

Dr. Pies puts the blame on the drug companies, but if you track the rise of this belief, it is easy to see that the American Psychiatric Association promoted it in some of their promotional materials to the public, and that “well-informed” psychiatrists often spoke of this metaphor in their interviews with the media. So what you find in this statement by Dr. Pies is a remarkable confession: psychiatry, all along, knew that the evidence wasn’t really there to support the chemical imbalance notion, that it was a hypothesis that hadn’t panned out, and yet psychiatry failed to inform the public of that crucial fact.

By doing so, psychiatry allowed a “little white lie” to take hold in the public mind, which helped sell drugs and of course made it seem that psychiatry had magic bullets for psychiatric disorders. That is an astonishing betrayal of the trust that the public puts in a medical discipline; we don’t expect to be misled in such a basic way.

But why now? Why are we hearing these admissions from Dr. Pies and others now? I am not sure, but I think there are two reasons.
One, the low-serotonin theory of depression has been so completely discredited by leading researchers that maintaining the story with the public has just become untenable. It is too easy for critics and the public to point to the scientific findings that contradict it.

Second, a number of pharmaceutical companies have shut down their research into psychiatric drugs [see Science, 2010], and they are doing so because, as they note, there is a lack of science providing good molecular targets for drug development. Even the drug companies are moving away from the chemical-imbalance story, and thus, what we are seeing now is the public collapse of a fabrication, which can no longer be maintained. In the statement by Dr. Pies, you see an effort by psychiatry to distance itself from that fabrication, putting the blame instead on the drug companies.

I want to summarize what’s going on. Psychiatry’s critics have long contended (of course I’m summarizing this in my own words and these don’t represent actual quotations):

Psychiatry’s “mental illnesses” are scientifically invalid. After decades of dedicated research, no pathophysiology, no biomarkers have been identified for these alleged disorders. They are not illnesses or disorders in the generally accepted medical sense, as prominent people in the field have known for decades. The idea that “mental illnesses” are due to a chemical imbalance in the brain is a myth, it is false, and prominent people in the field have been aware of this for decades. Psychiatry has played a double game of suggesting/implying/insinuating/claiming that they’re real medical illnesses in some contexts while admitting in others that these diagnoses have no scientific validity (see, for example, here and here). They should stop misleading the public in this way and fully acknowledge the lack of validity. Given that these are not illnesses, the utility of the DSM is in question, as are psychiatric drugs (especially in light of their known risks and harms). The use of these labels and especially forced or coercive drugging and the labeling and drugging of children urgently need to be reexamined.

Consider the first – bolded – part. That seems about as damning a critique of a field of medicine and scientific research as could exist. You can imagine if this criticism were directed at another field of medicine, or if such fatal weaknesses were alleged with regard to another medical intervention. What would happen? Masses of peer-reviewed evidence, of course, could and would be brought to bear disproving the claims of the critics and establishing the validity of the field’s diagnoses and the scientific foundation of the field itself. Whether or not the “skeptics” were convinced, this would be a relatively simple exercise, because this evidentiary basis exists. (Picture the piles placed in front of Michael Behe in the Dover trial.)

As Shulman noted, though, “Markedly different rules of science, logic and culture apply in psychiatry compared to medical science.” The response from psychiatry – and I’m not talking about a few fringe figures, but the head of NIMH, the people behind the DSM(s), and some of the most prominent people in the field – has been very different, along these lines:

Psychiatry’s “mental illnesses” are scientifically invalid. After decades of dedicated research, no pathophysiology, no biomarkers have been identified for these alleged disorders. They are not illnesses or disorders in the generally accepted medical sense, as we have known for decades. The idea that “mental illnesses” are due to a chemical imbalance in the brain is a myth, it is false, and we have been aware of this for decades. Sure, we’ve used medical terms, but the initiated knew that we meant something different by them than what’s commonly understood. And since we’re on the precipice of finding biomarkers and valid foundations, we’ve felt justified in employing this language. No one really believed the ridiculous chemical imbalance thing, and if they did we weren’t responsible. If anyone in the field promoted this idea, it was for their patients’ own good and did little real harm. We see nothing wrong with our medical language, and don’t consider that the fact that our diagnoses and model are scientifically invalid (to date! – but have faith!) has any implications for the use of the DSM or of psychiatric drugs, voluntary or otherwise.

Look at the overlap in the bolded portions. I’ve paraphrased from many sources here, but you could take statements from the strongest critics of biopsychiatry, mix them with those of leading psychiatric representatives, and people would be at a loss to identify which group the source came from. Psychiatry has not sought to deny that their diagnoses are scientifically invalid, or that the central myth – the chemical imbalance – is just that, or that they’ve known this all along. To be very clear: if your doctor has told you that you have a mental illness in the sense that we typically understand an illness, or that you suffer from a chemical imbalance, your doctor is giving you information disavowed by the profession itself. In the latter case, you’re being told a myth that leaders in psychiatry say they have long regarded as “antiquated,” an “urban legend,” and worthy of mockery as early as the 1970s. And they still expect you to accept the diagnosis and take the drugs. I ask you to ponder that for a while.

Struggles for scientific truth, as a part of larger social justice struggles, have a special feature. Their basic strength is that truth, ultimately, is not a function of power. In relatively open societies, even those as warped by capitalist and state power as ours, large institutions based on demonstrably false ideas are intrinsically fragile. Sadly, raw power has played a central role in the perpetuation of this myth and will be an important factor in its demise. As noted in the Levine/Whitaker interview, the exit of the pharmaceutical corporations from psychiatric drug development combined with the eventual expiration of existing patents will mean the loss of a powerful propaganda arm for both psychiatry and advocacy organizations.

As people who espouse science and humanism, who care about truth, the harms of pseudoscience, and humanrights, we have a responsibility to take action now rather than waiting for the inevitable collapse of biopsychiatry when it ceases to be profitable.

* This is the most important to me. It hadn’t occurred to me that anyone would think this. At the root of my mistake was, in addition to knowing my motives and thinking they would be apparent, that the books and articles I read in the area were by people who were very much concerned about people’s suffering – they don’t argue that people aren’t really suffering, but that they’re not suffering from a brain disease or disorder, and that the psychiatric model itself causes substantial suffering and harm.

** I have to note how much I detest phrases like this, from Hickey’s article: “The definition of a mental illness/disorder is not some kind of reality that the DSM-5 work group wrested from nature’s grudging bosom in the manner of real science,…” People who describe science using rape metaphors should be required to read Susan Griffin’s Woman and Nature. (I’m not suggesting that reading the book is a punishment, but that it would enlighten.)